Abstract
ABSTRACTBackground: Quality hospital services is reflected in the achieving of medical records. Improper medical record documentation would negatively affect the quality of service delivered to patients and it would disadvantage the hospital when medical disputes occur.Objective:Analyzing the management of medical record completeness at RSWN to guarantee the legality of medical record documents and its effect in supporting the completeness of medical record documents.Method:In this qualitative research, observation and interviews were conducted to 60 PJRM officers in the Arimbi ward, Banowati, Nakula I and Prabukresna. The obtained data were qualitatively and quantitatively analyzed based on several underlying theories.Results:The results showed that the completeness of some aspects includinghuman, money, method, material and machine elements was proper. The quantitative analysis showed 100%, while the qualitative analysis showed a percentage of 100% with the exception on the informed consent component with the potential for loss of 99%.Conclusions:The human element required periodic outreach to PPA. In the machine element, special computerswere needed for PJRM officers, and the importance of informed consent for patients undergoing hemodialysis to obtain medical records with strong legal force. Key Words :Management, Medical Record Completeness, Legality of Medical Records.
Highlights
Quality hospital services is reflected in the achieving of medical records
Results:The results showed that the completeness of some aspects includinghuman, money, method, material and machine elements was proper
Assessment of the documentation completeness level of the medical records in Basrah General Hospital
Summary
2017 dengan sampel 97 Dokumen didapatkan hasil kelengkapan review identifikasi sebesar 75,22%, review laporan penting (diagnosis) sebesar 82,53%, review autentikasi sebesar 73,10%, dan review pencatatan 28,75%(4). Faktor-faktor yang mempengaruhi kelengkapan dokumentasi Dokumen rekam medis (DRM) dari hasil penelitian diketahui dari faktor manusia yaitu kurangnya pengetahuan, motivasi, kedispilinan, beban kerja ysng tinggi serta komunikasi yang kurang. Padahal rekam medis merupakan bukti otentik atas pelayanan yang diberikan kepada pasien. Dalam berbagai kasus sengketa medis pada pelayanan kesehatan, rekam medis mempunyai peranan yang sangat penting sebagai bukti di pengadilan. Semakin legal perlindungan akan diberikan kepada pasien, dokter dan rumah sakit. Tanpa adanya dokumentasi rekam medis yang tercatat dengan lengkap akan dapat berdampak pada pelayanan kesehatan yang diberikan kepada pasien bahkan rumah sakit akan kesulitan untuk membuktikan bilamana ada gugatan hukum. Tidak terpenuhinya kelengkapan isian DRM di rumah sakit berdampak pada pemenuhan yang kurang optimal dari beberapa hak yang dimiliki oleh pasien, akibatnya rumah sakit dapat dikenai sanksi berdasarkan Pasal 46 Undang-
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